<style type="text/css" media="screen">

    .weui-cells__title{
        color:#000;
        font-size:17px;
    }
    .weui-cell::before{
        border-top:none;
    }
    .weui-cells::before{
        border-top:none;
    }
    .weui-cells::after{
        border-bottom: none;
    }
    .my-weui-cell{
        /* border-top: 1px solid #e5e5e5; */
        border-bottom: 1px solid #e5e5e5;
    }
    .page__hd {
        /* padding: 0px; */
        padding: 0px 5px;
        padding-top: 10px;
        /* border: 1px solid #000; */
    }
    .page__title{
        margin-top: 5px;
        font-size: 20px;
        color: #333;
        text-align: center;
    }
    /* .weui-input{
      width:100%;
      border: 1px solid #e5e5e5;
      outline:0;
      -webkit-appearance:none;
      background-color:transparent;
      font-size:inherit;
      color:inherit;
      height:2em;
      line-height:2em;
    } */
</style>
<form name="form1" id="form1"  role="form" data-toggle="validator" method="POST" action="">

    <div class="page">

        <div class="page__hd">
            <div class="page__title">
                  {$title}
            </div>
            <!-- <div class="page__desc">
                  <span style="color: red">提醒：</span>为保证您和大家的健康安全，以下信息如有变动请及时更新！
            </div> -->
            <!-- <div class="page__desc">
                  <hr>
            </div> -->
        </div>
        <div class="page__bd">
            <div class="weui-cells weui-cells_form">
                <div class ="my-weui-cell">
                    <div class="weui-cells__title"><label class="weui-label">1.姓名</label></div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input" type="text" required  name='row[nickname]' id='nickname' placeholder="请输入姓名" emptyTips="请输入姓名" >
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>

                <div class ="my-weui-cell">
                    <div class="weui-cells__title"><label class="weui-label">2.性别</label></div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r1">
                            <div class="weui-cell__hd">
                                <input required type="radio" class="weui-check" name="row[gender]" value="0" id="r1" tips="请选择性别">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">男</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r2">
                            <div class="weui-cell__hd">
                                <input required type="radio" class="weui-check" name="row[gender]" value="1" id="r2" tips="请选择性别">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">女</div>
                        </label>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>


                <div class ="my-weui-cell">
                    <div class="weui-cells__title">3.出生日期：</div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input datetime-picker" name='row[birthday_time]' id='birthday' type="text" required  placeholder="请输入出生日期" emptyTips="请输入出生日期" >
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>

                <div class ="my-weui-cell">
                    <div class="weui-cells__title">4.工号：</div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input" name='row[jobno]' id='jobno' type="text" required  placeholder="请输入工号" emptyTips="请输入工号" >
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>


                <div class="weui-cells__title"><label class="">5.所在教研室</label></div>
                <div style="margin-left: 10px">
                    <div class="weui-cell weui-cell_select">
                        <div class="weui-cell__bd">
                            <select required class="weui-select" name="row[cid]">
                                <option value="1">理信学院</option>
                            </select>
                        </div>
                    </div>

                    <div class="weui-cell weui-cell_select">
                        <div class="weui-cell__bd">
                            <select required="required" class="weui-select" name="row[crid]">
                                <option value="0">请选择教研室</option>
                                <option value="1">党政办</option>
                                <option value="2">学工办</option>
                                <option value="3">电信教研室</option>
                                <option value="4">计算机应用</option>
                                <option value="5">信息处理</option>
                                <option value="6">实验中心</option>
                                <option value="7">概率统计</option>
                                <option value="8">普物大物</option>
                                <option value="9">代数</option>
                                <option value="10">通信</option>
                                <option value="11">分析方程</option>
                                <option value="12">软件工程</option>
                            </select>
                        </div>
                    </div>
                </div>



                <div class ="my-weui-cell">
                    <div class="weui-cells__title">6.手机号：</div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input" type="tel" name='row[tel]' id='tel' required pattern="^\d{11}$" maxlength="11" placeholder="输入手机号" emptyTips="请输入手机号" notMatchTips="请输入正确的手机号">
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>

                <div class ="my-weui-cell">
                    <div class="weui-cells__title">7.家庭地址：</div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input city-picker" type="text" required name='row[family_address]' id='family_address' placeholder="请选择" emptyTips="家庭所在地" >
                            <input  type="hidden" required  id='family_province_code' name='row[family_province_code]' >
                            <input  type="hidden" required  id='family_city_code' name='row[family_city_code]' >
                            <input  type="hidden" required  id='family_district_code' name='row[family_district_code]' >
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>
                <div class ="my-weui-cell">
                    <div class="weui-cells__title">7.1.家庭具体地址：</div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input" type="text" required name='row[family_address_detail]' id='family_address_detail' placeholder="（具体到小区/村）" emptyTips="家庭所在地" >
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>

                <div class ="my-weui-cell">
                    <div class="weui-cells__title">8.当前地址：</div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input city-picker" type="text" required  name='row[current_address]' id='current_address' placeholder="请选择当前地址" emptyTips="当前所在地" >
                            <input  type="hidden" required  id='current_province_code' name='row[current_province_code]' >
                            <input  type="hidden" required  id='current_city_code' name='row[current_city_code]' >
                            <input  type="hidden" required  id='current_district_code' name='row[current_district_code]' >
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>
                <div class ="my-weui-cell">
                    <div class="weui-cells__title">8.1.当前具体地址：</div>
                    <div class="weui-cell">
                        <div class="weui-cell__bd">
                            <input class="weui-input" type="text" required name='row[current_address_detail]' id='current_address_detail' placeholder="（具体到小区/村）" emptyTips="当前所在地" >
                        </div>
                        <div class="weui-cell__ft">
                            <i class="weui-icon-warn"></i>
                        </div>
                    </div>
                </div>

                <div class ="my-weui-cell">
                    <div class="weui-cells__title">9.近15日内是否有乘坐1小时以上密闭公共交通经历？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a9_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" class="weui-check " name="row[a_9]" value="1" id="r_a9_1" >
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a9_2">
                            <div class="weui-cell__hd">
                                <input required type="radio" class="weui-check" name="row[a_9]" value="0" id="r_a9_2" >
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>


                <div class ="my-weui-cell">
                    <div class="weui-cells__title">10.自1月10日以来是否有武汉进出经历或接触湖北疫区？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a10_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" class="weui-check" name="row[a_10]" value="1" id="r_a10_1" tips="请对第10题做出选择">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a10_2">
                            <div class="weui-cell__hd">
                                <input  type="radio"  class="weui-check" name="row[a_10]" value="0" id="r_a10_2">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>

                <div id="a_10" style="display: none">
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">10.1. 进入武汉或湖北疫区日期:</div>
                        <div class="weui-cell">
                            <div class="weui-cell__bd">
                                <input class="weui-input datetime-picker" name='row[a_10_1]' id='a_10_1' type="text"   placeholder="请输入日期" emptyTips="请输入日期" >
                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">10.2. 离开武汉或湖北疫区日期：</div>
                        <div class="weui-cell ">
                            <div class="weui-cell__bd">
                                <input class="weui-input datetime-picker" name='row[a_10_2]' id='a_10_2'   type="text"   placeholder="请输入日期" emptyTips="请输入日期" >
                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">10.3. 进出原因</div>
                        <div class="weui-cell">
                            <div class="weui-cell__bd">
                                <textarea name="row[a_10_3]" id='a_10_3' disabled class="weui-textarea "   placeholder="请输入进出原因" emptyTips="请输入进出原因"></textarea>

                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">10.4. 交通方式（含车次、航班号）</div>
                        <div class="weui-cell">
                            <div class="weui-cell__bd">
                                <input class="weui-input" type="text"  disabled name='row[a_10_4]' id='a_10_4' placeholder="请输入交通方式" emptyTips="请输入交通方式" >

                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">10.5.目前自己及身边亲人身体状况是否出现异常？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a10.5_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" class="weui-check" disabled name="row[a_10_5]" value="1" id="r_a10.5_1" tips="请对第10.5题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a10.5_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio"  class="weui-check" disabled name="row[a_10_5]" value="0" id="r_a10.5_2">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>

                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">10.6.是否汇报当地居委会/村委会？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a10.6_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" class="weui-check" disabled name="row[a_10_6]" value="1" id="r_a10.6_1" tips="请对第10.6题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a10.6_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio"  class="weui-check" disabled name="row[a_10_6]" value="0" id="r_a10.6_2">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>
                </div>


                <div class ="my-weui-cell">
                    <div class="weui-cells__title">11.是否近15日从湖北疫区抵达青岛？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a11_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" class="weui-check" name="row[a_11]" value="1" id="r_a11_1" tips="请对第11题做出选择">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a11_2">
                            <div class="weui-cell__hd">
                                <input  type="radio"  class="weui-check" name="row[a_11]" value="0" id="r_a11_2">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>
                <div id="a_11" style="display: none">
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">11.1. 抵达日期:</div>
                        <div class="weui-cell">
                            <div class="weui-cell__bd">
                                <input class="weui-input datetime-picker" name='row[a_11_1]' id='a_11_1' type="text"  disabled placeholder="请输入抵达日期" emptyTips="请输入抵达日期" >
                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>

                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">11.2. 交通方式（含车次、航班号）</div>
                        <div class="weui-cell">
                            <div class="weui-cell__bd">
                                <input class="weui-input" type="text"  disabled name='row[a_11_2]' id='a_11_2' placeholder="请输入交通方式" emptyTips="请输入交通方式" >
                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>

                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">11.3.是否在居家隔离？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a11.3_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" class="weui-check" disabled name="row[a_11_3]" value="1" id="r_a11.3_1" tips="请对第11.3题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a11.3_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio"  class="weui-check" disabled name="row[a_11_3]" value="0" id="r_a11.3_2">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">11.4.自己及身边亲人身体是否出现异常？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a11.4_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" class="weui-check" disabled name="row[a_11_4]" value="1" id="r_a11.4_1" tips="请对第11.4题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a11.4_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio"  class="weui-check"checked disabled name="row[a_11_4]" value="0" id="r_a11.4_2">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">11.5.是否汇报当地居委会/村委会？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a11.5_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" class="weui-check" disabled name="row[a_11_5]" value="1" id="r_a11.5_1" tips="请对第11.5题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a11.5_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio" class="weui-check" disabled name="row[a_11_5]" value="0" id="r_a11.5_2" >
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>

                </div>


                <div class ="my-weui-cell">
                    <div class="weui-cells__title">12.是否近15日从省外抵达山东？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a12_1">
                            <div class="weui-cell__hd">
                                <input type="radio" required name="row[a_12]" class="weui-check"  value="1" id="r_a12_1" tips="请对第12题做出选择">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a12_2">
                            <div class="weui-cell__hd">
                                <input type="radio" required name="row[a_12]"  class="weui-check" value="0" id="r_a12_2">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>
                <div id="a_12" style="display: none">

                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">12.1. 抵达日期:</div>
                        <div class="weui-cell">
                            <div class="weui-cell__bd">
                                <input class="weui-input datetime-picker" name='row[a_12_1]' id='a_12_1' type="text"  disabled placeholder="请输入抵达日期" emptyTips="请输入抵达日期" >
                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>

                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">12.2. 交通方式（含车次、航班号）</div>
                        <div class="weui-cell">
                            <div class="weui-cell__bd">
                                <input class="weui-input" type="text"  disabled name='row[a_12_2]' id='a_12_2' placeholder="请输入交通方式" emptyTips="请输入交通方式" >
                            </div>
                            <div class="weui-cell__ft">
                                <i class="weui-icon-warn"></i>
                            </div>
                        </div>
                    </div>

                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">12.3.是否在居家隔离？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a12.3_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" name="row[a_12_3]" class="weui-check" disabled value="1" id="r_a12.3_1" >
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a12.3_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio"  name="row[a_12_3]" disabled class="weui-check" value="0" id="r_a12.3_2" tips="请对第12.3题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">12.4.自己及身边亲人身体是否出现异常？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a12.4_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" name="row[a_12_4]" class="weui-check" disabled value="1" id="r_a12.4_1" tips="请对第12.4题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a12.4_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio"  name="row[a_12_4]" disabled class="weui-check" value="0" id="r_a12.4_2">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>
                    <div class ="my-weui-cell">
                        <div class="weui-cells__title">12.5.是否汇报当地居委会/村委会？</div>
                        <div class="weui-cells weui-cells_checkbox">
                            <label class="weui-cell weui-check__label" for="r_a12.5_1">
                                <div class="weui-cell__hd">
                                    <input  type="radio" name="row[a_12_5]" class="weui-check" disabled value="1" id="r_a12.5_1" tips="请对第12.5题做出选择">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">是</div>
                            </label>
                            <label class="weui-cell weui-check__label" for="r_a12.5_2">
                                <div class="weui-cell__hd">
                                    <input  type="radio"  name="row[a_12_5]" disabled class="weui-check" value="0" id="r_a12.5_2">
                                    <i class="weui-icon-checked"></i>
                                </div>
                                <div class="weui-cell__bd">否</div>
                            </label>
                        </div>
                    </div>
                </div>


                <div class ="my-weui-cell">
                    <div class="weui-cells__title">13.近15日内是否接触过确诊病例？？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a13_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_13]" id="r_a13_1" class="weui-check"  value="1"  >
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a13_2">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_13]" id="r_a13_2" class="weui-check" value="0">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>



                <div class ="my-weui-cell">
                    <div class="weui-cells__title">14.近15日内是否接触过疑似病例或从疫区返鲁人员？？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a14_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_14]" id="r_a14_1" class="weui-check"  value="1"  >
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a14_2">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_14]" id="r_a14_2" class="weui-check" value="0">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>



                <div class ="my-weui-cell">
                    <div class="weui-cells__title">15.近15日内直系亲属有无被确诊？？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a15_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_15]" id="r_a15_1" class="weui-check"  value="1"  >
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a15_2">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_15]" id="r_a15_2" class="weui-check" value="0">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>


                <div class ="my-weui-cell">
                    <div class="weui-cells__title">16.目前是否在青岛农业大学校园内？？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a16_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_16]" id="r_a16_1" class="weui-check"  value="1"  >
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a16_2">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_16]" id="r_a16_2" class="weui-check" value="0">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>


                <div class ="my-weui-cell">
                    <div class="weui-cells__title">17.本人是否有发烧、干咳、乏力等异常表现？</div>
                    <div class="weui-cells weui-cells_checkbox">
                        <label class="weui-cell weui-check__label" for="r_a17_1">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_17]" id="r_a17_1" class="weui-check"  value="1"  >
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">是</div>
                        </label>
                        <label class="weui-cell weui-check__label" for="r_a17_2">
                            <div class="weui-cell__hd">
                                <input required type="radio" name="row[a_17]" id="r_a17_2" class="weui-check" value="0">
                                <i class="weui-icon-checked"></i>
                            </div>
                            <div class="weui-cell__bd">否</div>
                        </label>
                    </div>
                </div>

                <input type="hidden" name="row[latitude]" id="latitude" value="">
                <input type="hidden" name="row[abc]" id="abc" value="">


                <input type="hidden" name="row[longitude]" id="longitude" value="">

                <!-- <a href="javascript:;" id="datePickerBtn" class="weui-btn weui-btn_default">DatePicker</a> -->
            </div>
            <div  style="margin-top: 15px;">
                <button id="formSubmitBtn" type="submit" class="weui-btn weui-btn_success">提交</button>
            </div>
        </div>
    </div>
</form>

<script src="https://res.wx.qq.com/open/js/jweixin-1.4.0.js" type="text/javascript" charset="utf-8"></script>
<script type="text/javascript" charset="utf-8">
    wx.config({$wxjs});
    wx.ready(function () {
        wx.getLocation({
            type: 'wgs84', // 默认为wgs84的gps坐标，如果要返回直接给openLocation用的火星坐标，可传入'gcj02'
            success: function (res) {
                var latitude = res.latitude; // 纬度，浮点数，范围为90 ~ -90
                var longitude = res.longitude; // 经度，浮点数，范围为180 ~ -180。
                //var speed = res.speed; // 速度，以米/每秒计
                //var accuracy = res.accuracy; // 位置精度
                $("#latitude").val(latitude);
                $("#abc").val(latitude);
                $("#longitude").val(longitude);
                alert(latitude);
            },
            cancel: function (res) {
                alert('请允许获取位置');
                window.location.reload();
            }
        });
    })
</script>